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					                              LONDON BOROUGH OF MERTON
                                RESIDENT PARKING PERMIT
                                   APPLICATION FORM
All sections must be completed (please use CAPITAL LETTERS).
Note Declaration overleaf.

TITLE (e.g. Mr/Mrs/Miss/Ms)            SURNAME                                    FIRST NAME


ADDRESS

                                                             POSTCODE

TEL: NO(s) HOME                                           MOBILE

BLUE BADGE HOLDERS: If issued by LB Merton, please supply serial number
All other Badge holders please supply a photocopy of both sides.

Are you on the existing Electoral Roll at the above address? YES                        NO

PROOF OF RESIDENCE: If you are not on the Electoral Roll, please supply other evidence, referring to
the attached leaflet (or website). PLEASE DO NOT SEND ORIGINAL DOCUMENTATION.

Please tick boxes of documentary proof supplied
Tenancy                Proof                Utility                Driving             Other
agreement              of purchase           Bills (2)              Licence


Vehicle Registration Number                                       Vehicle Type please tick     Car      Van

Make Of Vehicle                                          Colour
& Model
PROOF OF VEHICLE OWNERSHIP: Please tick boxes of documentary proof supplied.
PLEASE DO NOT SEND ORIGINAL DOCUMENTATION.

Vehicle Registration          Insurance                  Hire                       Other
                              Certificate                Agreement                 Give details


Permits are issued for 6 or 12 months please tick your requirement: 12 months                     6 months



                                        HELPLINE 020 8545 4661


Your personal information will be held and used in accordance with the requirements of the
Data Protection Act 1998. We have a duty to protect the public funds we administer and may
use the information you provide for the prevention and detection of fraud. We may also share
this information with other bodies responsible for auditing or administering public funds for these
purposes. For further information, go to http://www.merton.gov.uk/legal/nfi-fdp.htm or contact
the Data Protection Officer, by email: data.protection@merton.gov.uk or by ‘phone 020 8545
4182. Further information is available from http://www.auditcommission.gov.uk/nfi/fpindex.asp
Please sign and date the declaration below.

DECLARATION
I declare that I have read the Residents Parking Permit leaflet or the London Borough of Merton’s
website on Residential Parking www.merton.gov.uk and agree to the terms and conditions of permit
issue. I further declare that:
i) all the information given in this application is correct.

ii) I reside principally at the address shown in this application (i.e. for at least four days and nights per
week) and the motor vehicle described is kept and used by me.

iii) if, during the current term of any permit, I cease to reside at the address declared as my principal
place of abode and/or I cease to be the keeper or user of the vehicle specified in this application I will
destroy the Permit or return it to the Parking Services Section of the London Borough of Merton and
understand that it will be an offence for me to continue to use the permit.

iv) I understand that making a false statement to procure a permit is a serious criminal offence and could
lead to prosecution by the Council on fraud charges.

In making this application I understand that authorised officers of the London Borough of Merton may
check statements made in this application against the Electoral Roll.


                                                     Full Name
Signature                                            (in block
                                                      capitals)


Return completed form to: Parking Services
                          Merton Civic Centre,
                          London Road,                                            Date
                          Morden,
                          Surrey. SM4 5DX


PAYMENT
I enclose a cheque/postal order for the sum of £_________ made payable to the London Borough of
Merton. Please write the applicant’s name and address on the reverse of the cheque.
         CARD PAYMENT – BARCLAYCARD, MASTERCARD, VISA, MAESTRO, SWITCH, DELTA ONLY.
             PLEASE NOTE: A surcharge of 1.56% is applied to payments made by CREDIT card
To the London Borough of Merton:
Please debit my card with the amount of £


CARD NO

Name
On Card                                                        Start Date           Expiry Date

Signature                                                             Switch Card Issue Number
& Date

Full address (including postcode) to which card is registered (if different from application
address):


                                                                       POSTCODE

				
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